Managing Obesity in Adults With Heart Failure

Podcast Transcript

Announcer:

Welcome to Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute at Cleveland Clinic. This podcast will explore the latest innovations, medical and surgical treatments, diagnostic testing, research, technology and practice improvements.

Tamanna Singh, MD:

Hi, everyone. Thanks so much for joining us today. I'm Dr. Tamanna Singh. I'm the director of our Sports Cardiology Center as well as our stress lab here today.

Amanda Vest, MBBS:

My name is Amanda Vest. I'm a heart failure cardiologist, meaning I look at the weakness and stiffness of the heart in our Section of Heart Failure and Cardiac Transplantation.

Tamanna Singh, MD:

Amanda, let's get started here. Tell us a little bit about the relationship between obesity and heart failure and why it's really important to start addressing both of them together.

Amanda Vest, MBBS:

Thank you so much. Well, we do know that carrying extra weight during life is a major risk factor for having heart conditions, and particularly this heart condition called heart failure with preserved ejection fraction, which means when somebody starts to experience shortness of breath, fatigue during exertion, perhaps some swelling in their body, and it's secondary to the heart being stiff. So, that pumping function is still okay, but the heart is stiff.

And really, obesity, along with high blood pressure, are the major risk factors at this time, especially in the USA, for the development of this heart condition. Maintaining a normal-range weight during life is one of the most powerful things for preventing the occurrence of this heart failure syndrome. But even once somebody has the heart failure syndrome, there are things that we're learning that can be very useful about addressing weight as a way to feel better. It's also possible that carrying extra weight may be a risk factor for developing weakness of the heart as well, although there, the relationship is a little less tight.

Tamanna Singh, MD:

Okay. Can you tell us a little bit about how many people with obesity are typically impacted by heart failure, whether it be the stiffening of the heart or the reduced ability to contract?

Amanda Vest, MBBS:

Well, we're all at risk. In fact, the most recent data that has been published shows that once we're age 40, there's a one-in-four lifetime risk of developing the heart failure syndrome, and that goes up even a little bit more for somebody who has extra weight. It's especially carrying the weight around our middles; that seems to be the most biologically active and the most deleterious for the heart.

That's why this is an important piece for us to think about, but we're in a great time at the moment in terms of new therapies. We want to chat a little bit more about the ways in which patients who have this condition may be helped by some of our treatments.

Tamanna Singh, MD:

Oh, certainly. I think particularly here, where obesity is clearly an epidemic, it's something I think we need to address with every patient that we see. Certainly, through my lens, I think the first thing I start with is focusing on how much movement and what kind of movement can we safely do to really start to work on some of that abdominal obesity, or obesity wherever else on your body, to start to chip away at some of that risk at developing heart failure.

Amanda Vest, MBBS:

It can be difficult to start that conversation, though, for some patients. We very much recognize that some of our patients may have had challenges in the healthcare system. They may not have always had positive responses to seeking care to help them with that extra weight. So, we really, in our clinics here, try to come to these conversations mindful that it may be an uncomfortable topic for some, maybe not for others, but address it sensitively, ask what one has tried before already, what has worked, what hasn't worked, to start picking away on the best next steps.

Tamanna Singh, MD:

Oh, I certainly agree. I mean, weight is still a huge stigma here. Like you mentioned, I think we have to be incredibly sensitive and understanding. I still think it's a way to empower our patients to kind of take ahold of what their body is trying to tell them, and then certainly put themselves into an advantageous place where they can start to utilize some of the treatment modalities and the things that we can do with our own bodies to help at least reduce some of that risk of heart failure as individuals continue to live.

Amanda Vest, MBBS:

Whether a patient who's seeking care for obesity has no heart failure or already has heart failure, we have members of our team who all collaborate together in the treatment plan, right? So, who do you work with?

Tamanna Singh, MD:

Oh, well, I work with colleagues like you in the heart failure section. I think it's really important to have patients actively engaged and empowered to understand why certain medications are used, whether they be specifically for weight loss or, also in tandem, medications for managing their heart failure.

We have wonderful pharmacists here. I know you guys work with a number of them who help to tee up medications, make sure our patients are tolerating them.

Then, from my lens, I love working with our registered dietitians and our nutritionists, who are predominantly with our prevention section.

We're talking a lot here about individuals who may already have both obesity and heart failure, but we certainly want to talk about individuals who may have obesity or have some extra weight on them who can start now learning about their history, working with other cardiologists, specifically in prevention in general, in heart failure, our dietitians, working with pharmacists so that they can actively engage and be a bit more preventive when it comes to developing heart failure.

Amanda Vest, MBBS:

And you're an exercise expert. What's an exercise physiologist or an exercise prescription?

Tamanna Singh, MD:

Oh, that's an excellent question. Here at the Cleveland Clinic, we actually have exercise physiologists, as well as trained cardiologists, who actually will look at individuals, have them come in to do a preliminary stress test or an exercise test to get a sense of what their exercise capacity is. From there, we can look at numbers like blood pressure, heart rate, an individual's ability to tolerate exercise either for longer or for greater intensity and use those little nuggets of information to develop an exercise plan.

We can actually safely implement that exercise plan, either in the individual's home or with our cardiac rehabilitation program here, which is a dedicated, three-times-a-week, three-month program where individuals are actively engaged with our exercise physiologist, with our physician on-site where we're measuring blood pressure, measuring heart rate, evaluating for symptoms, and, slowly but surely, increasing intensity, exercise duration, overall exercise volume so that individual can graduate from cardiac rehab with more tools and feeling stronger.

So it's a great way to learn, be engaged, meet other people, get psychosocial support, and again, empower yourself to take ahold of the obesity and the heart failure, and really have the best sense of control, so that way, you can really work from a preventive mindset.

Amanda Vest, MBBS:

Yes. Often, feeling strong, being able to do things, being able to breathe better during activity is the metric that we're looking for, and not always so much what the number says on the scales. Right?

Tamanna Singh, MD:

Totally. Exactly. I mean, I think you're alluding to a little bit about the BMI or the body mass index, which, I think, in both of our lines of work, just is a huge disservice to individuals. It really doesn't give me information about lean muscle mass and body fat proportions. I think, unfortunately, because that, as well as the number on the scale, is so ingrained with respect to who is, quote, unquote, "fat" or obese and who is not, I think, leaves all of us just feeling a little less about ourselves.

So, we really want to be mindful about how we actually measure body fat, lean muscle mass, and then use that to really help us determine what the best strategy for weight loss is. What are some of the strategies for weight loss?

Amanda Vest, MBBS:

As you described, dietary interventions ideally guided by a registered dietitian and those exercise plans are the cornerstone of any treatment plan around obesity. That's certainly the case if a patient has heart failure. Now, we know that for our patients with heart failure, especially those with more severe symptoms, it can be challenging to participate in high levels of activity. Actually, the research that we have shows that even the best exercise plans probably don't achieve that much change in body weight, although they may make you feel stronger, fitter and less symptomatic.

We are really learning so much now about our medications for metabolic health. As many of our listeners will be aware, medications such as semaglutide, tirzepatide, these are the once-weekly injectable medicines that have been studied and FDA-approved for type 2 diabetes, have subsequently gained approvals for treatment of obesity and are now, as we'll talk about, even shown to be helpful for people who have obesity plus that stiff heart condition, as well as those who have other medical concerns, like sleep apnea, for example, with the tirzepatide.

These medications work in several ways to reduce appetite, and we're learning a lot from our patients about how, for some, that food noise can be an incredibly challenging part of their health experience.

In those who are able to have less of the hunger that they may have been experiencing, it can be a real game-changer in terms of focusing on those lifestyle pieces that you just described.

There are also metabolic pathways that help to put inflammation more under control, as well as help us in the way that fat stores and glucose stores are managed. For many of our patients, quite significant weight loss over time may be possible. We're talking about only wanting to lose one to two pounds a week, if one is watching the scales. Maybe you aren't even watching the scales, and that can be part of a plan as well.

Then over the course of a year or more, many patients can lose quite a significant amount of weight. Interestingly, those who have a stiff heart have been shown in two large clinical trials to have, not only improvements in their heart failure symptoms, their shortness of breath, being able to do activity scores, but also, it would seem, in their ability to stay away from fluid retention and even stay out of hospital, it seems. Increasingly, these are being considered as medications that may be helpful to the overall heart failure syndrome.

Now, we have other medicines as well. You may be on a medicine such as empagliflozin, dapagliflozin, spironolactone, eplerenone, finerenone. Those may all be medicines that are familiar to our audience with a heart condition. But this one, specifically for people, especially with extra weight around the middle, can really help improve their stability and their ability to be active and feel well. So, we're pretty excited about that.

Tamanna Singh, MD:

I'm very excited about it. I mean, you kind of lean into it already. The more movement we can get as we lose weight with the benefit and the help of these medications, I think, again, it empowers the individual to engage and develop those lifestyle behaviors that they can carry through if they ever are able to potentially stop those medications or titrate the doses. I think it's exciting for many cardiologists' point of view.

Amanda Vest, MBBS:

Now, we're still learning quite a lot. Those trials that we have for patients with stiff hearts, we don't have the same sort of clinical trial for our patients with heart failure with reduced ejection fraction, meaning a weakened heart. For those patients who may also be living with obesity, it may well be important and appropriate to treat that weight, because patients with obesity do tend to have more symptoms, higher risk of hospitalizations, and it can be particularly problematic around accessing things like transplantation.

So there, you'll see us being particularly mindful of the pros and the cons, speaking carefully to patients and monitoring very closely. I think, as you may have heard, in the heart failure clinic, we have a specific metabolic heart failure team. A few of us doctors, two of our pharmacists, and then, in conjunction with the dietitians and exercise physiologists work to a specific protocol.

And we're very careful to be seeing those patients every four weeks, often over our video or telephone encounter opportunities, but checking in very closely about symptoms and making sure patients are doing okay, both in terms of their breathing and fluid retention and in terms of those gastrointestinal symptoms, which we do have to manage carefully and are one of the major limitations of these medicines.

Tamanna Singh, MD:

Can you talk a little bit more about some of the side effects that you see for our audience?

Amanda Vest, MBBS:

Yeah. There are a few questions your clinician will ask you about potential rare scenarios where it may not be appropriate for you to take this type of medication. So that's one of the important things that has to be covered first, and then they should talk to you about how, in slowing down the gut's activity with this medication, that's part of the way it works, it can cause people to feel nauseous, have abdominal pain after eating. Some may even get vomiting. Some may get constipation or diarrhea.

In general, the way we prescribe these, to start at a very low dose. Every four weeks, reassess, and if the tolerance is good, go up gradually. Sometimes we need to drop down on a dose. Sometimes we have to stay put, and sometimes even give patients a break from them. But there are things that people can do in terms of modulating their eating a little bit to help their stomach settle on these medications as well. So definitely worth collaborating closely with both the prescriber and the dietitian to get those tips.

Tamanna Singh, MD:

That's wonderful. I mean, it sounds like, particularly when we're hearing about obesity and heart failure, two major things that can impact our audience's lives. It gives me comfort to know that we have a very, very robust, consistent program for individuals to engage in where they can have this active involvement from a multidisciplinary team and just active feedback going on about how well they're feeling, how they're tolerating their medications and then certainly some of that dose titration. I think that's a huge strength and credit to your program.

Amanda Vest, MBBS:

Yes and we're very grateful for the collaboration of the prevention group, our dietitians, pharmacists, exercise physiologists, and also our bariatric surgery team, because for some patients who either maybe don't respond well to the medications or don't get quite to the health goals they were aiming at, it may still be very appropriate to talk with the bariatric and metabolic surgery team about the possibility of something like a lap sleeve gastrectomy, which is a type of weight management surgical procedure.

So, there are wonderful specialists across the clinic who may all be involved in your care at various stages. Anything you'd like to let our patients and their families know about the experience of coming to Cleveland Clinic and what to expect?

Tamanna Singh, MD:

I think what our audience can hopefully get from our conversation is that we truly work with our team of teams, our team of specialists to ensure that we're approaching all of our patients with an independent mindset, with an individualized mindset as well. And I think most of us come from a place of empowering our patients to take ahold and take control of their health, but also engage with experts so that we can be mindful, intellectual about that.

What I'm getting from our conversation here today is that there's multiple ways to address obesity, certainly from the onset, trying to go from a lens of prevention. Then certainly, with the diagnosis of heart failure alongside obesity, leaning into our lifestyle changes, leaning into some of these new weight loss medications that have proven to be beneficial for those with stiffer hearts, and then finally, certainly engaging our surgical colleagues if we do need to open that door and consider surgery. So, I think we have a wonderful plan for every potential patient who has questions and concerns about obesity and heart failure, and I hope they come and seek us out if they ever need any assistance.

Amanda Vest, MBBS:

Absolutely. We're learning so much more about the biology of this situation. Our audience may be interested to hear that no longer do we think of that extra weight just as inert tissue there. We know that those adipocytes, those fat cells are incredibly metabolically active, driving this inflammation and secreting chemicals into the body, which are harmful to the heart.

So, the more we learn about that, the more we understand how different medications can be complementary to the dietary and exercise approaches. Here at Cleveland Clinic, we do a lot of research, and there are indeed some of those trials of new therapies now starting to combine different mechanisms of action, and one of those trials is being run out of our research center here.

I do think it's important that we emphasize that although we have the STEP-HFpEF, STEP-HFpEF DM, and SUMMIT studies for our patients with preserved ejection fraction, we don't know so much about our heart failure with reduced ejection fraction patients and the safety of the GLP-1 agonists in that setting. Some of our colleagues may remember that there were some concerns in small studies using liraglutide in patients with advanced HFrEF in the past, maybe worsening of the heart failure, stability and excess of atrial and ventricular arrhythmias.

One thing we just saw published in JACC: Heart Failure last week was a study by Marques et. al., looking at a small, propensity-matched cohort of patients in Canada who had implantable cardiac devices, heart failure with reduced ejection fraction, and were on GLP-1 agonists. They did see that increase in heart rate, which we've seen in other non-heart failure studies, average of seven beats per minute, and a elevated rate of nonsustained ventricular tachycardia.

So, this echoes some of those earlier concerns. Personally, in my metabolic heart failure program, I feel quite strongly that patients should have a defibrillator if one is indicated, if you're starting obesity-dosed GLP-1 agonist therapy, and that you need to keep an eye on that defibrillator recording for any of those issues. It is a high-risk group. Sometimes the benefits certainly outweigh the risks, but close monitoring is really the message there.

Tamanna Singh, MD:

Those are some key points there, and I'm excited to see the research come out as we learn more about HFrEF and some of these medications.

Amanda Vest, MBBS:

More to come. More that we're learning. It's not just a case of “exercise more, eat less” these days. We're really starting to understand the biology between obesity and the heart to help our patients in a more meaningful way.

We welcome referrals into our heart failure clinic across the spectrum of ejection fraction. It's particularly those patients with advanced heart failure with reduced ejection fraction who may need to be considered for the advanced therapies, a ventricular assist device, heart transplantation, or some of the investigational device therapies, as well as those patients with heart failure with preserved ejection fraction who are very limited or who need that multidisciplinary experience in terms of their obesity management. We know a lot of people are prescribing GLP-1s, but it's understandable that not everybody feels comfortable when heart failure is also a comorbidity.

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